Implementation of the WHO core components of an infection prevention and control programme in two sub-saharan African acute health-care facilities: a mixed methods study.

BACKGROUND: The coronavirus pandemic again highlighted the need for robust health care facility infection prevention and control (IPC) programmes. WHO guidelines on the core components (CCs) of IPC programmes provides guidance for facilities, but their implementation can be difficult to achieve in resource-limited settings. We aimed to gather evidence on an initial WHO IPC implementation experience using a mixed methods approach. METHODS: A five-day training on the WHO IPC CCs was conducted at two reference acute health care facilities in the Democratic Republic of Congo and Burkina Faso. This was accompanied by a three-part mixed-methods evaluation consisting of a: (1) baseline and follow-up survey of participants' knowledge, attitudes and practices (KAP), (2) qualitative assessment of plenary discussion transcripts and (3) deployment of the WHO IPC assessment framework (IPCAF) tool. Results were analysed descriptively and with a qualitative inductive thematic approach. RESULTS: Twenty-two and twenty-four participants were trained at each facility, respectively. Baseline and follow-up KAP results suggested increases in knowledge related to the necessity of a dedicated IPC focal person and annual evaluations of IPC training although lack of recognition on the importance of including hospital leadership in IPC training and hand hygiene monitoring recommendations remained. Most participants reported rarely attending IPC meetings or participating in IPC action planning although attitudes shifted towards stronger agreement with the feeling of IPC responsibility and importance of an IPC team. A reocurring theme in plenary discussions was related to limited resources as a barrier to IPC implementation, namely lack of reliable water access. However, participants recognised the importance of IPC improvement efforts such as practical IPC training methods or the use of data to improve quality of care. The facilities' IPCAF scores reflected a 'basic/intermediate' IPC implementation level. CONCLUSIONS: The training and mixed methods evaluation revealed initial IPC implementation experiences that could be used to inform stepwise approaches to facility IPC improvement in resource-limited settings. Implementation strategies should consider both global standards such as the WHO IPC CCs and specific local contexts. The early involvement of all relevant stakeholders and parallel efforts to advocate for sufficient resources and health system infrastructure are critical.

Infection prevention and control between legal requirements and German Society for Hygiene and Microbiology expert assessments: a cross-sectional study in September-November 2022.

BACKGROUND: In contrast to the beginning of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), pandemic, more and more hospital issues are now regulated by policy. AIM: To identify differences between expert recommendations and legal requirements regarding infection prevention and control (IPC) strategies. METHODS: A cross-sectional study was conducted between 29th September 2022 and 3rd November 2022 addressing 1319 members of the German Society for Hygiene and Microbiology. The response rate was 12%. This paper reports the expert recommendations on different IPC strategies. FINDINGS: The majority (66%) of experts recommended universal mask usage, with 34% recommending it seasonally, even after the SARS-CoV-2 pandemic. Medical microbiology (MM) experts were more likely to recommend continuing to wear the masks indefinitely compared with IPC experts. Concerning the mask type, medical masks were recommended more frequently by IPC experts (47.3%), while FFP2 masks were preferred by MM experts (31.8%). The majority (54.7%) of experts recommended universal screening of employees, mainly in settings with extremely vulnerable patients and if regional incidence rates were high, at a frequency of twice per week. The dominant advice (recommended by at least 50% of experts) for employees exposed to SARS-CoV-2 was daily testing and wearing a mask, regardless of the length of exposure. CONCLUSIONS: Expert recommendations deviate from the legal requirements and appear to be more differentiated and proportional. The influence of specific experience and expertise on mask recommendations should be investigated in more detail. For relevant policy decisions, a quick, focused and broad-based consultation of expertise could be of added value.

Epidemiology of healthcare-associated SARS-CoV-2 outbreaks in Germany between March 2020 and May 2022.

BACKGROUND: Outbreaks in healthcare facilities played a pivotal role in the course of the coronavirus (COVID-19) pandemic. AIM: To investigate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks in hospitals, outpatient care, and rehabilitation facilities in Germany from March 2020 to May 2022. METHODS: Data from the German mandatory notification system were used to describe outbreaks by number of cases and case fatality ratio (CFR), and outbreak cases by age and gender. Using Pearson correlation, the dynamics of cases in the general population were compared with cases in healthcare-associated infection (HAI) SARS-CoV-2 outbreaks before and after the start of the vaccination campaign. Additionally, a counterfactual scenario was used to estimate numbers of prevented HAI cases, using the phase before vaccination as baseline. FINDINGS: By the end of May 2022, 8941 healthcare-associated outbreaks were observed with 73,626 cases: 51,504 in hospitals, 15,524 in outpatient care, and 6598 in rehabilitation facilities. Median number of cases per outbreak was 4 (range: 2-342) and cases were more frequently reported in women with 46,818 (63.6%). Overall CFR was 8.1%, higher in men (12.4%) than in women (5.7%). After the vaccination campaign was fully introduced, the association between increasing incidence in the general population and consecutive outbreak cases was decreased by a factor of 10. Furthermore, our counterfactual analysis suggests that more than 55,000 outbreak cases could have been prevented until the end of 2021. CONCLUSION: The vaccination campaign in combination with non-pharmaceutical measures was key to reduce number, size and CFR of healthcare-associated outbreaks.

Implementation of the WHO hand hygiene strategy in Faranah regional hospital, Guinea.

BACKGROUND: Healthcare-associated infections are the most frequent adverse events in healthcare worldwide, with limited available evidence suggesting highest burden in resource-limited settings. Recent Ebola epidemics emphasize the disastrous impact that spread of infectious agents within healthcare facilities can have, accentuating the need for improvement of infection control practices. Hand hygiene (HH) measures are considered to be the most effective tool to prevent healthcare-associated infections. However, HH knowledge and compliance are low, especially in vulnerable settings such as Guinea. The aim of PASQUALE (Partnership to Improve Patient Safety and Quality of Care) was to assess knowledge and compliance with HH and improve HH by incorporating the WHO HH Strategy within the Faranah Regional Hospital (FRH), Guinea. METHODS: In a participatory approach, a team of FRH staff and leadership was invited to identify priorities of the hospital prior to the start of PASQUALE. The local hygiene committee was empowered to increase its activities and take ownership of the HH improvement strategy. A baseline assessment of knowledge, perception and compliance was performed months before the intervention. The main intervention consisted of local alcohol-based-hand-rub (ABHR) production, with final product efficacy testing, in conjunction with a training adapted to the needs identified in the baseline assessment. A follow-up assessment was conducted directly after the training. Effectiveness of the intervention was assessed via uncontrolled before-and-after comparison. RESULTS: Baseline knowledge score (13.0/25) showed a significant increase to 19.0/25 in follow-up. Baseline-Compliance was 23.7% and increased significantly to 71.5% in follow-up. Compliance rose significantly across all professional groups except for midwifes and in all indications for HH, with the largest in the indication "Before aseptic tasks". The increase in compliance was associated with the intervention and remained significant after adjusting for confounders. The local pharmacy successfully supplies the entire hospital. The local supply resulted in a ten-fold increase of monthly hospital disinfectant consumption. CONCLUSION: The WHO HH strategy is an adaptable and effective method to improve HH knowledge and compliance in a resource-limited setting. Local production is a feasible method for providing self-sufficient supply of ABHR to regional hospitals like the FRH. Participatory approaches like hygiene committee ownership builds confidence of sustainability.

Early Detection of Infection Chains & Outbreaks: Use Case Infection Control.

Within the HiGHmed Project there are three medical use cases. The use cases include the scopes cardiology, oncology and infection. They serve to specify the requirements for the development and implementation of a local and federated platform, with the result that data from medical care and research should be retrievable, reusable and interchangeable. The Use Case Infection Control aims to establish an early detection of transmission events as well as clusters and outbreaks of various pathogens. Therefore the use case wants to establish the smart infection control system (SmICS).

Evaluation of the statutory surveillance system for invasive MRSA infections in Germany, 2016-2017.

BACKGROUND: Mandatory notification of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections was introduced for laboratories in Germany in 2009. The aims were to support local health authorities (LHAs) in their mandate to prevent and control infections in hospitals and to improve population-based nationwide surveillance of healthcare associated infections. We evaluated the MRSA surveillance system to assess whether its aims were met and to identify areas for improvement. METHODS: Using the updated guidelines for evaluating public health surveillance systems by the Centers for Disease Control and Prevention we assessed the attributes simplicity, timeliness, data quality, acceptability, and usefulness. In 2016/2017 we interviewed staff in LHAs, state health authorities (SHAs), and laboratories and analyzed surveillance data of cases notified between 2009 and 2016. RESULTS: We interviewed 10% of LHAs (n = 38), 63% of SHAs (n = 10), 5 selected laboratories and analyzed information on 27,706 notified MRSA cases. LHAs reported that on receiving notifications from laboratories they contacted hospitals for clinical information, which was time-consuming and complicated as physicians were hard to reach or refused to answer questions, citing doctor-patient confidentiality. LHAs suggested reducing the amount of information collected as some clinical information was unnecessary for implementing control measures. LHAs stated that they received notifications on time, however surveillance data analysis showed some delay. Data completeness exceeded 90% for most variables, however it was only 68% and 80% for dates of disease onset and hospital admission respectively making it impossible to discriminate between hospital and community acquired infections in half of the cases. The surveillance system was well accepted by half of the interviewees. A third however stated that the benefits of the surveillance system were outweighed by the work associated with it. The majority rated the system to be useful for recognizing trends in the MRSA incidence and the ability to check up on infection control measures in hospitals. CONCLUSIONS: The surveillance system proved to be useful by fulfilling its aims. It was timely, acceptable and provided complete data for most variables. However, the system was complicated; ensuring that only relevant variables are reported could simplify the system without losing any of its usefulness.

Routine screening for colonization by Gram-negative bacteria in neonates at intensive care units for the prediction of sepsis: systematic review and meta-analysis.

BACKGROUND: At neonatal intensive care units, sepsis due to Gram-negative bacteria is an important cause of morbidity and mortality. The benefits of routine microbiological screening of neonatal body surface to predict and prevent sepsis are controversial. AIM: To evaluate the prognostic value of neonatal body surface screening for colonization with Gram-negative bacteria for the prediction of late-onset sepsis. METHODS: A systematic review was performed, including studies of any design that reported data to calculate prognostic accuracy of surface screening for the prediction of late-onset sepsis. Risk of bias was assessed and a meta-analysis performed. Evidence quality was appraised using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. FINDINGS: Eight studies (all cohort design) were identified as eligible. Studies were performed in six countries in Europe, Asia, and North America and comprised a total of 4829 participants. All studies were at high risk of bias. Pooled sensitivity of body surface screening to predict late-onset sepsis was 41% (95% confidence interval: 17-70), whereas pooled specificity was 56% (34-76) (hierarchical summary receiver operating characteristics (HSROC) model). Subgroup analyses showed higher pooled estimates for specificity but not sensitivity when screening focused on Escherichia coli or Klebsiella pneumoniae. GRADE evidence quality was very low. CONCLUSION: Limited evidence of very low quality exists regarding the prognostic value of neonatal screening for late-onset sepsis. Carefully planned and conducted prospective studies, including randomized trials, are needed to clarify the potential value of this measure for the prediction and prevention of late-onset sepsis.

Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases.

INTRODUCTION: In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. MATERIALS AND METHODS: A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. CONCLUSION: The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

Large hospital outbreak of KPC-2-producing Klebsiella pneumoniae: investigating mortality and the impact of screening for KPC-2 with polymerase chain reaction.

BACKGROUND: Multi-drug-resistant Klebsiella pneumoniae carbapenemase (KPC)-2-producing K. pneumoniae are an increasing cause of healthcare-associated infections worldwide. AIMS: To investigate the impact of clinical infection on mortality, and examine the effect of use of KPC-2-specific polymerase chain reaction (PCR) on the time to contact isolation during an outbreak. METHODS: Cases were defined as patients clinically infected or colonized with KPC-2-producing K. pneumoniae between June 2010 and July 2012. Cases were described by demographic and health characteristics, and the association between infection and mortality, adjusted for comorbidities and demographic characteristics, was determined using Poisson regression with robust standard errors. A comparison was made between the time to contact isolation with a culture-based method and PCR using Wilcoxon's rank sum test. FINDINGS: Of 72 cases detected, 17 (24%) had undergone transplantation and 21 (29%) had a malignancy. Overall, 35 (49%) cases were clinically infected, with pneumonia and sepsis being the most common infections. Infection was an independent risk factor for mortality (risk ratio 1.67, 95% confidence interval 0.99-2.82). The median time to contact isolation was 1.5 days (range 0-21 days) using PCR and 5.0 days (range 0-39 days) using culture-based methods (P = 0.003). Intermittent negative tests were observed in 48% (14/29) of cases tested using culture-based methods. CONCLUSION: KPC-2-producing K. pneumoniae mainly affect severely ill patients. Half of the cases developed clinical infection, associated with increased risk of death. As PCR accelerates isolation and provides the opportunity for preventive measures in colonized cases, its use should be implemented promptly during outbreaks. Further studies are needed to enhance knowledge about KPC detection patterns and to adjust screening guidelines.

[Surveillance of antibiotic consumption in hospitals: tasks of the Public Health Service]. / Surveillance des Antibiotikaverbrauchs in Krankenhäusern : Aufgaben des öffentlichen Gesundheitsdienstes.

According to the German Protection Against Infection Act (IfSG; section 23 paragraph 4, July 2011), hospitals and clinics for ambulatory surgery are obliged to establish a continuous monitoring of antibiotic consumption in their institute. The introduction of the surveillance of antibiotic consumption aims to contribute to an optimization of antibiotic prescription practices in order to confine the development and spread of resistant pathogens. The local public health authority is entitled to supervise the implementation of legal requirements in the hospital setting. The main aim of this article is to support local public health authorities in coping with this task by providing background information on the surveillance of antibiotic consumption and its role as a key component of antibiotic stewardship programs. Furthermore, criteria suitable for assessing the implementation of a functioning surveillance system are proposed. The possibilities and limitations of the activities of public health authorities in this context are addressed.

[Prevalence of carbapenemase-producing bacteria in hospitals in Saxony, Germany]. / Prävalenzerhebung zum Vorkommen von Carbapenemase-Bildnern in sächsischen Kliniken.

The presence of pathogenic bacteria with acquired carbapenem resistance constitutes an increasing problem for infection control and infectious disease management. Prompted by an outbreak of infections with Klebsiella pneumoniae producing the carbapenemase KPC-2 at a hospital in Saxony, the Saxon State Ministry of Social Affairs and Consumer Protection (SMS) initiated a point-prevalence survey for carbapenemase-producing gram-negative bacteria. Wards at 53 hospitals in Saxony, mainly intensive care units, were investigated between October 2012 and February 2013. Stool samples and rectal swabs of 1,037 patients were analyzed for the presence of bacteria with resistance against four major groups of antibiotics (4MRGN). Carbapenemase producers were detected in 3 patients [0.3% CI95 (0.0596; 0.843)] and carbapenem-resistant bacteria without carbapenemases were detected in 9 patients [0.9% CI95 (0.397; 1.64)]. Furthermore, antimicrobial susceptibility testing revealed 166 patients [16.0% CI95 (13.82; 18.38)] with extended-spectrum beta-lactamase (ESBL)-producing bacteria. At the time of investigation, K. pneumoniae producing the carbapenemase KPC-2 was diagnosed in 2 patients at one hospital. Moreover, it is necessary to remain vigilant towards other types of carbapenemase producers, as demonstrated by the finding of a Pseudomonas aeruginosa strain harbouring the carbapenemase VIM-1 in another hospital.

How many outbreaks of nosocomial infections occur in German neonatal intensive care units annually?

BACKGROUND: Outbreaks on neonatal intensive care units (NICUs) achieve huge media interest, but the real number of neonatal outbreaks within a country is unknown. METHOD: This calculation is based on the data of the component for nosocomial infections in very low birth weight (VLBW) infants of the German national nosocomial infection surveillance system (NEO-KISS) from 2006 to 2011. Almost all German NICUs caring for VLBW infants participated in this surveillance system. A cluster was defined and an outbreak was assumed when at least two cases of severe neonatal infection (bloodstream infection, pneumonia) occurred within a defined time interval in one center with the same pathogen species in different patients. Four different intervals were used for calculation: 14, 30, 60, and 90 days. Infections with coagulase-negative staphylococci (CoNS) were excluded. RESULTS: A total of 228 NICUs provided data in the six-year study period. A total of 37,038 VLBW infants and 1,361,950 patient days were used for the calculation. 7,405 severe neonatal infections occurred, and a microbiological detection of the pathogen was successful in 2,084 cases. Altogether, between 121 and 280 outbreaks were calculated according to the different time intervals used. Most outbreaks were due to Staphylococcus aureus, followed by Enterococcus spp. and Enterobacter spp. CONCLUSION: It can be assumed that at least between 26 and 61 neonatal outbreaks with at least two severe infections take place in German NICUs per year. The actual number seems to be higher because only laboratory-confirmed infections in a subgroup of patients were used for the analysis.

[Surveillance of antibiotic consumption : clarification of the "definition of data on the nature and extent of antibiotic consumption in hospitals according to § 23 paragraph 4 sentence 2 of the IfSG"]. / Antibiotika-Verbrauchs-Surveillance : Ausführungen und Erläuterungen zur Bekanntmachung "Festlegung der Daten zu Art und Umfang des Antibiotika-Verbrauchs in Krankenhäusern nach § 23 Abs. 4 Satz 2 IfSG"

According to § 23 paragraph 4 of the German Infection Prevention Act (IfSG; July 2011), hospitals and clinics for ambulatory surgery are obliged to establish a continuous monitoring system of antibiotic consumption. This is aimed at contributing to an optimization of antibiotic prescription practices in order to confine the development and spread of resistant pathogens. The general requirements (restricted to hospitals) on the method and extent of data collection are provided by the national public health institution after discussion with representatives of various professional societies (Robert Koch-Institut, Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 59, 2013). The article aims to clarify these specifications and to provide background details. In agreement with national and European surveillance systems, the Anatomical Therapeutic Chemical (ATC)/Defined Daily Dose (DDD) classification system recommended by the WHO should be used as reference standard. Antibiotic consumption should be expressed as the number of DDDs per 100 patient days and per 100 admissions. The categories of antimicrobials and hospital organizational units to be monitored and the time intervals in which analyses should be conducted are determined. Furthermore, various approaches of data assessment are described.

[Hospital surveillance during major outbreaks of community-acquired diseases. Pandemic Influenza Hospital Surveillance (PIKS) 2009/2010 and Surveillance of Bloody Diarrhea (SBD) 2011]. / Krankenhaus-Surveillance während großer Ausbrüche ambulant erworbener Erkrankungen. Die Pandemische-Influenza-Krankenhaus-Surveillance (PIKS) 2009/2010 und die Surveillance blutiger Durchfälle (SBD) 2011.

BACKGROUND AND OBJECTIVE: During the influenza pandemic 2009/2010 and the outbreak of entero-haemorrhagic Escherichia coli (EHEC)/hemolytic-uremic syndrome (HUS) 2011, the statutory reporting system in Germany was complemented by additional event-related surveillance systems in hospitals. The Pandemic Influenza Hospital Surveillance (PIKS) and the Surveillance of Bloody Diarrhea (SBD) were evaluated, to make experiences available for similar future situations. METHODS: The description and evaluation of our surveillance systems is based on the "Updated Guidelines for Evaluating Public Health Surveillance Systems" published by the U.S. Centers for Disease Control and Prevention in 2001. RESULTS: PIKS and SBD could be implemented quickly and were able to capture resilient data in a timely manner both on the severity and course of the influenza pandemic 2009/2010 and the outbreak of EHEC and HUS 2011. Although lacking in representativeness, sensitive and useful data were generated. CONCLUSION: In large outbreaks of severe diseases, the establishment of specific hospital surveillance should be considered as early as possible. In Germany, the participating hospitals were able to rapidly implement the required measures.

[Antimicrobial resistance in Germany. Four years of antimicrobial resistance surveillance (ARS)]. / Daten zur Antibiotikaresistenzlage in Deutschland. Vier Jahre Antibiotika-Resistenz-Surveillance (ARS).

In 2007, the Robert Koch Institute established the infrastructure for the national Antimicrobial Resistance Surveillance (ARS) system. Laboratories submit data of routine susceptibility testing of clinical samples from hospitals as well as from outpatient care settings in a standardized format to the Robert Koch Institute for central processing. The database for the period 2008-2011 comprises data of about 1.3 million samples from patients in hospital care and almost 800,000 samples from outpatients. Based on SIR interpretations of susceptibility, the trends of methicillin resistance of Staphylococcus aureus (MRSA) and cefotaxime non-susceptibility as an indicator of extended-spectrum beta-lactamases (ESBL) of Escherichia coli and Klebsiella pneumoniae were analyzed for four care settings or categories: hospital care, outpatient care, intensive care units, and isolates from blood cultures. After constant high levels of above 20%, the proportion of MRSA isolates showed a decline for the first time from 2010 to 2011 in hospital care overall, in intensive care units as well as in blood cultures; in outpatient care, MRSA proportions of about 13% were observed. Within the observed period, non-susceptibility to cefotaxime as an indicator of ESBL in E. coli showed an increasing trend in hospital care at a level above 10% in intensive care units, while cefotaxime non-susceptibility in K. pneumoniae was more frequent but without any trend. In outpatient care, the proportions of cefotaxime non-susceptibility increased year by year in both species resulting in nearly a doubling to 6%.

Evidence for airborne infectious disease transmission in public ground transport--a literature review.

While guidelines on contact tracing (CT) after exposure to certain infectious pathogens during air travel exist, no guidance documents are available on CT in response to potential exposure on public ground transport. We reviewed scientific and non-scientific literature on transmission of airborne pathogens in public ground transport and on factors potentially influencing transmission. We identified 32 relevant publications (15 scientific and 17 non-scientific). Most of the selected studies dealt with transmission of tuberculosis. However, the relation between travel duration, proximity to the index case and environmental factors, such as ventilation, on disease transmission in public ground transport is poorly understood. Considering the difficulty and probably limited effectiveness of CT in ground transport, our results suggest that only exceptional circumstances would justify CT. This contrasts with the high level of attention CT in air travel seems to receive in international regulations and recommendations. We question whether the indication for CT should be revisited after a risk­benefit assessment that takes into account exposure in both ground and air transport.

Quantitative assessment of passenger flows in Europe and its implications for tracing contacts of infectious passengers.

In contrast to air travel, there are no recommendations on tracing ground transport passengers exposed to infectious pathogens. We analysed European statistics on passenger transport in different conveyances and conducted expert workshops to discuss environmental conditions in ground transport, indications and minimal datasets required for contact tracing. Transport performance in the 27 countries of the European Union increased from 5.3 x 10(12) passenger kilometres (pkm) in 1995 to 6.5 x 10(12) pkm in 2007. Each resident generated on average 13,092 pkm in 2007, of which 2,062 pkm were public ground transport and 1,155 pkm in air transport. In the same year in Germany the total passenger volume in all different conveyances was 67,937 million. Public ground transport accounted for a passenger volume of 11,387 million (16.8%) and air transport for 129 million (0.2%). High efficiency particulate air (HEPA) filtration is frequently used in airplanes but not in ground transport vehicles. Therefore opportunities for disease transmission in public ground transport are not necessarily lower than in air travel. However, contact tracing is rarely conducted in these settings because of immense logistic challenges.Indication for contact tracing should be revisited, including all kinds of passenger transport.